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PITTSBURGH, January 29, 1997 — Despite the many advances made in the treatment of chronic insomnia in recent years, researchers at the University of Pittsburgh Medical Center's Western Psychiatric Institute and Clinic question whether most physicians have enough information to properly diagnose and treat it.

In an article in today's New England Journal of Medicine (NEJM), David J. Kupfer, M.D., and Charles F. Reynolds III, M.D., stress the importance primary care physicians hold as the primary resource for treating chronic insomnia, yet worry that many cases are misdiagnosed or undertreated because doctors do not have the latest information.

"Chronic insomnia is a symptom of a deeper problem, not a disorder itself," explains Dr. Kupfer, Thomas Detre Professor and chairman, department of psychiatry. "There are often many causes underlying a person's inability to get a good night's sleep. If a physician fails to recognize or treat those underlying causes, someone suffering from chronic insomnia can face more serious problems later. Physicians need to keep that in mind when they decide whether to treat the patient themselves or seek help from a specialist."

The nearly 30 million people in the United States who suffer with insomnia are more likely to be in an automobile accident, get hurt on the job, develop dependence on alcohol or other drugs, or develop mood disorders like depression, the researchers say.

"Chronic insomnia is serious," says Dr. Reynolds, professor of psychiatry and neurology, "yet there is far too little attention paid to it as a symptom of either hidden psychiatric or medical illness. Physicians, especially family doctors, need to learn more about how to diagnose and treat it."

In the NEJM review article, the authors say doctors need to establish a diagnostic approach that allows them to choose from among many different types of therapy.

"Most cases of chronic insomnia can be treated with either one or a combination of education, behavioral intervention or medication. The basic aim of education or behavioral intervention is to re-establish the link between the bedroom and sleep. Patients learn what activities help or inhibit sleep," explains Dr. Kupfer. "With their doctor's help, many people can modify their behavior and restore their ability to sleep well.

"Medications are used successfully to relieve insomnia, but their use requires close supervision. They must be prescribed in the lowest effective dose and for no more than three to four weeks," he cautions.

The authors stress that a physician must carefully evaluate a patient's complaint of insomnia before starting any treatment. A doctor should learn all possible causes, which could include medical conditions such as sleep-disordered breathing or nocturnal myoclonus (restlessness of the legs at the beginning of sleep); use of substances such as alcohol, caffeine or nicotine; or mood disorders like acute or chronic stress or depression; or disordered circadian rhythms brought on by shift work or jet lag.

"It's often useful to have patients complete a two-week diary of their sleep habits, including normal bedtime and wake times, what they eat, how often and when they exercise and what medications they may be taking," advises Dr. Reynolds.

Once a treatment program has been established, the doctor must follow the patient's progress and watch for signs of relapse.

"Chronic insomnia defies easy diagnosis or treatment," acknowledges Dr. Kupfer. "Even so, the bottom line is that once the underlying problems are identified and worked through, a successful treatment plan can be implemented."

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